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How to cialis best buy cite this http://www.bcfreshsales.com/can-you-buy-cialis-over-the-counter-in-canada/ article:Singh OP. Mental health in diverse India. Need for cialis best buy advocacy. Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of. We have diversity in terms of geography cialis best buy – From the Himalayas to the deserts to the seas.

Every region has its own distinct culture and food. There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude toward women, health infrastructure, cialis best buy child mortality, and other sociodemographic development indexes. There is now ample evidence that sociocultural factors influence mental health. Compton and Shim[1] have described in their model of gene environment interaction how public policies and social norms act on the distribution of opportunity leading to social inequality, exclusion, poor environment, discrimination, and cialis best buy unemployment.

This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low cialis best buy access to health care leads to poor mental health, disease, and morbidity.When we come to the field of mental health, we find huge differences between different states of India. The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood onset cialis best buy disorders.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates cialis best buy of depression and anxiety were found in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms. Marriage was found to be a negative prognostic indicator contrary to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are cialis best buy apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders.

The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions. Apart from culture bound syndromes, the role of cultural idioms of cialis best buy distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1–5 lakhs, it was 41,197, and in higher income group, it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy aimed at promoting rights of mentally ill cialis best buy persons and reducing stigma and discriminations. It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population.

Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done at institutional level, cialis best buy organizational level, and individual level. There has been huge work done in this regard at institution level. Important research work done in this regard includes the National Mental Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden of Diseases in Indian cialis best buy States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.

Similarly, at organizational level, the Indian Psychiatric Society (IPS) has filed a case cialis best buy for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality. The IPS has also started helplines at different levels and media interactions. The Indian Journal of Psychiatry has also cialis best buy come out with editorials highlighting the need of care of marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation.

When the enemy is economic inequality, our weapon is research highlighting the role of these cialis best buy factors on mental health. References 1.Compton MT, Shim RS. The social cialis best buy determinants of mental health. Focus 2015;13:419-25. 2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al.

National Mental Health cialis best buy Survey of India, 2015-16. Prevalence, Patterns and Outcomes. Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No. 129.

2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India. The Global Burden of Disease Study 1990–2017. Lancet Psychiatry 2020;7:148-61.

4.National Crime Records Bureau, 2019. Accidental Deaths and Suicides in India. 2019. Available from. Https://ncrb.gov.in.

[Last accessed on 2021 Jun 24]. 5.Machado DB, Rasella D, dos Santos DN. Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_635_21Abstract Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, and cultural factors on the one hand and while on the other hand, biological aspects, genetic predisposition, and associated mental and physical illnesses. Sexual health is a neglected area, even though it influences mortality, morbidity, and disability.

Dhat syndrome (DS), the term coined by Dr. N. N. Wig, has been at the forefront of advancements in understanding and misunderstanding. The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as “a culturally determined idiom of distress.” It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments.

Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients. The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature.

It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.Keywords. Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome. A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr.

President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020. I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr. Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research. His name carries the reverence in the corridors of the current National Institute of Mental Health and Neuro Sciences (NIMHANS) at Bangalore which was All India Institute of Mental Health, when he served as Head and the Medical Superintendent.

Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS). Even though Dr. Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore – Dr.

Abraham Varghese, the first Editor of the Indian Journal of Psychological Medicine and Dr. K. Kuruvilla, Past Editor of Indian Journal of Psychiatry whose legacies I carried forward for both the journals. I must place on record that my journey in the field of Sexual Medicine was sown by Dr. K.

Kuruvilla and subsequent influence of Dr. Ajit Avasthi from Postgraduate Institute of Medical Education and Research from Chandigarh as my role model in the field. There are many more who have shaped and nurtured my interest in the field of sex and sexuality.The term “Dhat” was taken from the Sanskrit language, which is an important word “Dhatu” and has known several meanings such as “metal,” a “medicinal constituent,” which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for “loss of semen”, and the DS is a well-known “culture-bound syndrome (CBS).”[4] The DS leads to several psychosexual disorders such as physical weakness, tiredness, anxiety, appetite loss, and guilt related to the loss of semen through nocturnal emission, in urine and by masturbation as mentioned in many studies.[4],[5],[6] Conventionally, Charaka Samhita mentions “waste of bodily humors” being linked to the “loss of Dhatus.”[5] Semen has even been mentioned by Aristotle as a “soul substance” and weakness associated with its loss.[6] This has led to a plethora of beliefs about “food-blood-semen” relationship where the loss of semen is considered to reduce vitality, potency, and psychophysiological strength. People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions. Several past studies have emphasized that CBS leads to “anxiety for loss of semen” is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area.

Tiwari et al.[22] mentioned in their study that “culture is closely associated with mental disorders through social and psychological activities.” With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome. A Separate Entity or a “Cultural Variant” of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved. It has mostly been conceptualized as a multidimensional psychosomatic entity consisting of anxiety, depressive, somatic, and sexual phenomenology. Most importantly, abnormal and erroneous attributions are considered to be responsible for the genesis of DS.

The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?. There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders.

Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue. Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively. Depression continued to be reported as the most common association of DS in many studies.[25],[26] This “cause-effect” dilemma can never be fully resolved. Whether “loss of semen” and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument. However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness.

Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management. He also mentions that the underlying “emotional distress and cultural contexts” are not unique to DS but can be related to any psychiatric syndrome for that matter. On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of “mood disorders” can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a “cultural phenotype” of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.

Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent. The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners. A psychiatric referral occurs much later, if at all.

This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder. Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders. The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being. Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS.

That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome. The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as “semen loss syndrome” by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with “semen loss anxiety” suffer from a myriad of psychosexual symptoms, which have been attributed to “loss of vital essence through semen” (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale.

The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms. Most commonly associated symptoms were found as per score ≥1. This study reported several parameters such as the “sense of being unhealthy” (99%), worry (99%), feeling “no improvement despite treatment” (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%). The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness.

Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic. Most of them have sexual neurosis (Shen-K'uei syndrome).[7] More than one-third of the patients belonged to lower social class and symptoms of depression, somatization, anxiety, masturbation, and nocturnal emissions. Other bodily complaints as reported were sleep disturbances, fatigue, dizziness, backache, and weakness. Nearly 80% of them considered that all of their problems were due to masturbatory practices.De Silva and Dissanayake[8] investigated several manifestations on semen loss syndrome in the psychiatric clinic of Colombo General Hospital, Sri Lanka. Beliefs regarding effects of semen loss and help-seeking sought for DS were explored.

38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years. Every participant reported excessive loss of semen and was preoccupied with it. The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss.

Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing “Dhat” in urine. They were assessed for a period of 6 months. More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety.

All the participants felt that their symptoms were due to loss of “dhat” in urine, attributed to excessive masturbation, extramarital and premarital sex. Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan. About 600 educated patients were included as per Bradford Somatic Inventory (BSI). Men with DS reported greater symptoms on BSI than those without DS.

60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for “Dhat” items on BSI. The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness. This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire.

Nearly one-third of the patients were passing “Dhat” multiple times a week. Among them, nearly 60% passed almost a spoonful of “Dhat” each time during a loss. This work on sexual disorders reported that the passage of “Dhat” was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%). Mostly, the participants experienced passage of Dhat as “night falls” (60.1%) and “while passing stools” (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the “loss of Dhat.” The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure.

Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%. It was found that 57.5% were suffering either from comorbid depression or anxiety disorders. The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban). One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction.

The psychosexual symptoms were found among 113 patients who had DS. The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%). In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice. The view of participants was that semen is very “precious,” needs preservation, and masturbation is a malpractice. Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders.

Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively. The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments. About 66% of the patients met the DSM-IV diagnostic criteria of depression. They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety.

The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through “nocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.” The assessment was done based on several indices, namely “Somatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.” Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis. Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia).

Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India. They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic. Clinical assessments were done apart from detailed sexual history. The patients were 15–50 years of age, educated up to mid-school and mostly from a rural background.

Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age. There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16–23 years). The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill.

It was assumed in the study that semen loss is considered synonymous to “loss of something precious”, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and “Dhat” in urine (40%) were the common complaints observed. Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache. More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia.

About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders). Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse. 67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%).

Hypochondriasis, sexually transmitted diseases, and depression were the associated comorbidities. Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms. DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains. The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation.

Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas. In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%–66.7%) were from rural areas, belonged to “conservative families and posed rigid views about sex” (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class. Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss.

They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment. The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class.

Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%). The subjects were single or unmarried (51.0%) and married (46.7%). About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes. Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%).

About 45.80% of the study subjects were illiterates and very few had completed postgraduation. The subjects were both married and single. Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).

Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16–20 years (34%) followed by 21–25 years (28%), greater than 30 years (26%), 26–30 years (10%), and 11–15 years (2%). Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively. Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine.

In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years. The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%). Priyadarshi and Verma[43] performed a study in 110 male patients with DS. The average age of the patients was 23.53 years and it ranged between 15 and 68 years.

The most affected age group of patients was of 18–25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years. Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively.

Two-third patients belonged to rural areas of residence. Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata. The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset.

Only a few patients received higher education. Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training. Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%).

Most of those who had comorbid DS symptoms received minimal formal education. Management. A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks. As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal “supplements,” etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help.

The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals. Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone. Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality.

This needs to be tailored to the local terminology and beliefs. Biofeedback has also been proposed as a treatment modality.[4] Individual stress factors that might have precipitated DS need to be addressed. A detailed outline of assessment, evaluation, and management of DS is beyond the scope of this article and has already been reported in the IPS Clinical Practice Guidelines.[56] The readers are referred to these important guidelines for a comprehensive read on management. Probably, the most important factor is to understand and resolve the sociocultural contexts in the genesis of DS in each individual. Adequate debunking of the myths related to sexuality and culturally appropriate sexual education is vital both for the prevention and treatment of DS.[56] Adequate treatment of comorbidities such as depression and anxiety often helps in reduction of symptoms, more so when the DS is considered to be a manifestation of the same.

Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary. CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization. Sameer et al.[23] followed up DS patients for 6.0 ± 3.5 years and concluded that the “pure” variety of DS is not a stable diagnostic entity.

The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right “place” for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different. While ICD-10 considers DS under “other nonpsychotic mental disorders” (F48), DSM-V mentions it only in appendix section as “cultural concepts of distress” not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a “true syndrome.”[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural “idiom” of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification.

However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the “niche” of DS in the near future. It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader “narrative” of depression. In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric “construct” which is equally interesting and controversial. Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality.

Beyond the traditional debate about its “separate” existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health. It is also treatable, and hence, the detection, understanding, and awareness become vital to its management. This oration attempts a “bird's eye” view of this CBS taking into account a holistic perspective of the available evidence so far. The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr.

Debanjan Banerjee (Senior Resident, Department of Psychiatry, NIMHANS, Bangalore) for his constant selfless support, rich academic discourse, and continued collaboration that helped me condense years of research and ideas into this paper.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.2.3.Srinivasa Murthy R, Wig NN. A man ahead of his time. In. Sathyanarayana Rao TS, Tandon A, editors.

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Cultural perspectives related to international classification of diseases-11. Indian J Soc Psychiatry 2018;34 Suppl S1:1-4. Correspondence Address:T S Sathyanarayana RaoDepartment of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka IndiaSource of Support. None, Conflict of Interest. NoneDOI.

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NCHS Data Brief viagra vs cialis reviews http://www.ec-conseil-xv-strasbourg.site.ac-strasbourg.fr/?p=2729 No. 286, September 2017PDF Versionpdf icon (374 KB)Anjel Vahratian, Ph.D.Key findingsData from the National Health Interview Survey, 2015Among those aged 40–59, perimenopausal women (56.0%) were more likely than postmenopausal (40.5%) and premenopausal (32.5%) women to sleep less than 7 hours, on average, in a 24-hour period.Postmenopausal women aged 40–59 were more likely than premenopausal women aged 40–59 to have trouble falling asleep (27.1% compared with 16.8%, respectively), and staying asleep (35.9% compared with 23.7%), four times or more in the past week.Postmenopausal women aged 40–59 (55.1%) were more likely than premenopausal women aged 40–59 (47.0%) to not wake up feeling well rested 4 days or more in the past week.Sleep duration and quality are important contributors to health and wellness. Insufficient sleep is associated with an increased risk for chronic conditions such as cardiovascular disease (1) viagra vs cialis reviews and diabetes (2). Women may be particularly vulnerable to sleep problems during times of reproductive hormonal change, such as after the menopausal transition.

Menopause is “the permanent cessation of menstruation viagra vs cialis reviews that occurs after the loss of ovarian activity” (3). This data brief describes sleep duration and sleep quality among nonpregnant women aged 40–59 by menopausal status. The age range selected for this analysis reflects the focus on midlife sleep health. In this analysis, 74.2% of women are premenopausal, 3.7% are perimenopausal, and 22.1% are postmenopausal viagra vs cialis reviews.

Keywords. Insufficient sleep, menopause, National Health Interview Survey Perimenopausal viagra vs cialis reviews women were more likely than premenopausal and postmenopausal women to sleep less than 7 hours, on average, in a 24-hour period.More than one in three nonpregnant women aged 40–59 slept less than 7 hours, on average, in a 24-hour period (35.1%) (Figure 1). Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period (56.0%), compared with 32.5% of premenopausal and 40.5% of postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to sleep less than 7 hours, on average, in a 24-hour period.

Figure 1 viagra vs cialis reviews. Percentage of nonpregnant women aged 40–59 who slept less than 7 hours, on average, in a 24-hour period, by menopausal status. United States, 2015image icon1Significant quadratic trend viagra vs cialis reviews by menopausal status (p <. 0.05).NOTES.

Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or viagra vs cialis reviews less. Women were premenopausal if they still had a menstrual cycle. Access data table for Figure viagra vs cialis reviews 1pdf icon.SOURCE.

NCHS, National Health Interview Survey, 2015. The percentage of women aged 40–59 who had trouble falling asleep four times or more in the past viagra vs cialis reviews week varied by menopausal status.Nearly one in five nonpregnant women aged 40–59 had trouble falling asleep four times or more in the past week (19.4%) (Figure 2). The percentage of women in this age group who had trouble falling asleep four times or more in the past week increased from 16.8% among premenopausal women to 24.7% among perimenopausal and 27.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to have trouble falling asleep four times or more in the past week.

Figure 2 viagra vs cialis reviews. Percentage of nonpregnant women aged 40–59 who had trouble falling asleep four times or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by menopausal status (p viagra vs cialis reviews <. 0.05).NOTES.

Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had viagra vs cialis reviews a menstrual cycle and their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle. Access data viagra vs cialis reviews table for Figure 2pdf icon.SOURCE.

NCHS, National Health Interview Survey, 2015. The percentage of women aged 40–59 who had trouble staying asleep four times or more in the past week varied by menopausal status.More than one in four nonpregnant women aged 40–59 had trouble staying asleep four viagra vs cialis reviews times or more in the past week (26.7%) (Figure 3). The percentage of women aged 40–59 who had trouble staying asleep four times or more in the past week increased from 23.7% among premenopausal, to 30.8% among perimenopausal, and to 35.9% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to have trouble staying asleep four times or more in the past week.

Figure 3 viagra vs cialis reviews. Percentage of nonpregnant women aged 40–59 who had trouble staying asleep four times or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by viagra vs cialis reviews menopausal status (p <. 0.05).NOTES.

Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were viagra vs cialis reviews perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle. Access data table for viagra vs cialis reviews Figure 3pdf icon.SOURCE.

NCHS, National Health Interview Survey, 2015. The percentage of women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week varied by menopausal status.Nearly one in two nonpregnant women aged 40–59 did not wake up feeling well rested 4 days or more in the past week (48.9%) (Figure 4). The percentage of women in this age group who did viagra vs cialis reviews not wake up feeling well rested 4 days or more in the past week increased from 47.0% among premenopausal women to 49.9% among perimenopausal and 55.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to not wake up feeling well rested 4 days or more in the past week.

Figure 4 viagra vs cialis reviews. Percentage of nonpregnant women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by menopausal status (p <. 0.05).NOTES.

Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle. Access data table for Figure 4pdf icon.SOURCE.

NCHS, National Health Interview Survey, 2015. SummaryThis report describes sleep duration and sleep quality among U.S. Nonpregnant women aged 40–59 by menopausal status. Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period compared with premenopausal and postmenopausal women.

In contrast, postmenopausal women were most likely to have poor-quality sleep. A greater percentage of postmenopausal women had frequent trouble falling asleep, staying asleep, and not waking well rested compared with premenopausal women. The percentage of perimenopausal women with poor-quality sleep was between the percentages for the other two groups in all three categories. Sleep duration changes with advancing age (4), but sleep duration and quality are also influenced by concurrent changes in women’s reproductive hormone levels (5).

Because sleep is critical for optimal health and well-being (6), the findings in this report highlight areas for further research and targeted health promotion. DefinitionsMenopausal status. A three-level categorical variable was created from a series of questions that asked women. 1) “How old were you when your periods or menstrual cycles started?.

€. 2) “Do you still have periods or menstrual cycles?. €. 3) “When did you have your last period or menstrual cycle?.

€. And 4) “Have you ever had both ovaries removed, either as part of a hysterectomy or as one or more separate surgeries?. € Women were postmenopausal if they a) had gone without a menstrual cycle for more than 1 year or b) were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they a) no longer had a menstrual cycle and b) their last menstrual cycle was 1 year ago or less.

Premenopausal women still had a menstrual cycle.Not waking feeling well rested. Determined by respondents who answered 3 days or less on the questionnaire item asking, “In the past week, on how many days did you wake up feeling well rested?. €Short sleep duration. Determined by respondents who answered 6 hours or less on the questionnaire item asking, “On average, how many hours of sleep do you get in a 24-hour period?.

€Trouble falling asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble falling asleep?. €Trouble staying asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble staying asleep?.

€ Data source and methodsData from the 2015 National Health Interview Survey (NHIS) were used for this analysis. NHIS is a multipurpose health survey conducted continuously throughout the year by the National Center for Health Statistics. Interviews are conducted in person in respondents’ homes, but follow-ups to complete interviews may be conducted over the telephone. Data for this analysis came from the Sample Adult core and cancer supplement sections of the 2015 NHIS.

For more information about NHIS, including the questionnaire, visit the NHIS website.All analyses used weights to produce national estimates. Estimates on sleep duration and quality in this report are nationally representative of the civilian, noninstitutionalized nonpregnant female population aged 40–59 living in households across the United States. The sample design is described in more detail elsewhere (7). Point estimates and their estimated variances were calculated using SUDAAN software (8) to account for the complex sample design of NHIS.

Linear and quadratic trend tests of the estimated proportions across menopausal status were tested in SUDAAN via PROC DESCRIPT using the POLY option. Differences between percentages were evaluated using two-sided significance tests at the 0.05 level. About the authorAnjel Vahratian is with the National Center for Health Statistics, Division of Health Interview Statistics. The author gratefully acknowledges the assistance of Lindsey Black in the preparation of this report.

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Hyattsville, MD. National Center for Health Statistics. 2017.Copyright informationAll material appearing in this report is in the public domain and may be reproduced or copied without permission. Citation as to source, however, is appreciated.National Center for Health StatisticsCharles J.

Rothwell, M.S., M.B.A., DirectorJennifer H. Madans, Ph.D., Associate Director for ScienceDivision of Health Interview StatisticsMarcie L. Cynamon, DirectorStephen J. Blumberg, Ph.D., Associate Director for Science.

NCHS Data Brief No cialis best buy. 286, September 2017PDF Versionpdf icon (374 KB)Anjel Vahratian, Ph.D.Key findingsData from the National Health Interview Survey, 2015Among those aged 40–59, perimenopausal women (56.0%) were more likely than postmenopausal (40.5%) and premenopausal (32.5%) women to sleep less than 7 hours, on average, in a 24-hour period.Postmenopausal women aged 40–59 were more likely than premenopausal women aged 40–59 to have trouble falling asleep (27.1% compared with 16.8%, respectively), and staying asleep (35.9% compared with 23.7%), four times or more in the past week.Postmenopausal women aged 40–59 (55.1%) were more likely than premenopausal women aged 40–59 (47.0%) to not wake up feeling well rested 4 days or more in the past week.Sleep duration and quality are important contributors to health and wellness. Insufficient sleep is associated with an increased risk for cialis best buy chronic conditions such as cardiovascular disease (1) and diabetes (2). Women may be particularly vulnerable to sleep problems during times of reproductive hormonal change, such as after the menopausal transition. Menopause is “the permanent cessation of menstruation that occurs after the loss of cialis best buy ovarian activity” (3).

This data brief describes sleep duration and sleep quality among nonpregnant women aged 40–59 by menopausal status. The age range selected for this analysis reflects the focus on midlife sleep health. In this cialis best buy analysis, 74.2% of women are premenopausal, 3.7% are perimenopausal, and 22.1% are postmenopausal. Keywords. Insufficient sleep, menopause, National Health Interview Survey Perimenopausal women were cialis best buy more likely than premenopausal and postmenopausal women to sleep less than 7 hours, on average, in a 24-hour period.More than one in three nonpregnant women aged 40–59 slept less than 7 hours, on average, in a 24-hour period (35.1%) (Figure 1).

Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period (56.0%), compared with 32.5% of premenopausal and 40.5% of postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to sleep less than 7 hours, on average, in a 24-hour period. Figure 1 cialis best buy. Percentage of nonpregnant women aged 40–59 who slept less than 7 hours, on average, in a 24-hour period, by menopausal status. United States, cialis best buy 2015image icon1Significant quadratic trend by menopausal status (p <.

0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last cialis best buy menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle. Access data table for cialis best buy Figure 1pdf icon.SOURCE.

NCHS, National Health Interview Survey, 2015. The percentage of women aged 40–59 who had trouble falling asleep four times or more in the past week varied by menopausal status.Nearly one in five nonpregnant women aged 40–59 had trouble falling asleep four times or more in the past week (19.4%) cialis best buy (Figure 2). The percentage of women in this age group who had trouble falling asleep four times or more in the past week increased from 16.8% among premenopausal women to 24.7% among perimenopausal and 27.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to have trouble falling asleep four times or more in the past week. Figure 2 cialis best buy.

Percentage of nonpregnant women aged 40–59 who had trouble falling asleep four times or more in the past week, by menopausal status. United States, cialis best buy 2015image icon1Significant linear trend by menopausal status (p <. 0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 cialis best buy year ago or less.

Women were premenopausal if they still had a menstrual cycle. Access data cialis best buy table for Figure 2pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015. The percentage of women aged 40–59 who had cialis best buy trouble staying asleep four times or more in the past week varied by menopausal status.More than one in four nonpregnant women aged 40–59 had trouble staying asleep four times or more in the past week (26.7%) (Figure 3). The percentage of women aged 40–59 who had trouble staying asleep four times or more in the past week increased from 23.7% among premenopausal, to 30.8% among perimenopausal, and to 35.9% among postmenopausal women.

Postmenopausal women were significantly more likely than premenopausal women to have trouble staying asleep four times or more in the past week. Figure 3 cialis best buy. Percentage of nonpregnant women aged 40–59 who had trouble staying asleep four times or more in the past week, by menopausal status. United States, cialis best buy 2015image icon1Significant linear trend by menopausal status (p <. 0.05).NOTES.

Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and cialis best buy their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle. Access data table cialis best buy for Figure 3pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015.

The percentage of women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week varied by menopausal status.Nearly one in two nonpregnant women aged 40–59 did not wake up feeling well rested 4 days or more in the past week (48.9%) (Figure 4). The percentage of women in this age group who did not wake up cialis best buy feeling well rested 4 days or more in the past week increased from 47.0% among premenopausal women to 49.9% among perimenopausal and 55.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to not wake up feeling well rested 4 days or more in the past week. Figure 4 cialis best buy. Percentage of nonpregnant women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week, by menopausal status.

United States, 2015image icon1Significant linear trend by menopausal status (p <. 0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle.

Access data table for Figure 4pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015. SummaryThis report describes sleep duration and sleep quality among U.S. Nonpregnant women aged 40–59 by menopausal status. Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period compared with premenopausal and postmenopausal women.

In contrast, postmenopausal women were most likely to have poor-quality sleep. A greater percentage of postmenopausal women had frequent trouble falling asleep, staying asleep, and not waking well rested compared with premenopausal women. The percentage of perimenopausal women with poor-quality sleep was between the percentages for the other two groups in all three categories. Sleep duration changes with advancing age (4), but sleep duration and quality are also influenced by concurrent changes in women’s reproductive hormone levels (5). Because sleep is critical for optimal health and well-being (6), the findings in this report highlight areas for further research and targeted health promotion.

DefinitionsMenopausal status. A three-level categorical variable was created from a series of questions that asked women. 1) “How old were you when your periods or menstrual cycles started?. €. 2) “Do you still have periods or menstrual cycles?.

€. 3) “When did you have your last period or menstrual cycle?. €. And 4) “Have you ever had both ovaries removed, either as part of a hysterectomy or as one or more separate surgeries?. € Women were postmenopausal if they a) had gone without a menstrual cycle for more than 1 year or b) were in surgical menopause after the removal of their ovaries.

Women were perimenopausal if they a) no longer had a menstrual cycle and b) their last menstrual cycle was 1 year ago or less. Premenopausal women still had a menstrual cycle.Not waking feeling well rested. Determined by respondents who answered 3 days or less on the questionnaire item asking, “In the past week, on how many days did you wake up feeling well rested?. €Short sleep duration. Determined by respondents who answered 6 hours or less on the questionnaire item asking, “On average, how many hours of sleep do you get in a 24-hour period?.

€Trouble falling asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble falling asleep?. €Trouble staying asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble staying asleep?. € Data source and methodsData from the 2015 National Health Interview Survey (NHIS) were used for this analysis.

NHIS is a multipurpose health survey conducted continuously throughout the year by the National Center for Health Statistics. Interviews are conducted in person in respondents’ homes, but follow-ups to complete interviews may be conducted over the telephone. Data for this analysis came from the Sample Adult core and cancer supplement sections of the 2015 NHIS. For more information about NHIS, including the questionnaire, visit the NHIS website.All analyses used weights to produce national estimates. Estimates on sleep duration and quality in this report are nationally representative of the civilian, noninstitutionalized nonpregnant female population aged 40–59 living in households across the United States.

The sample design is described in more detail elsewhere (7). Point estimates and their estimated variances were calculated using SUDAAN software (8) to account for the complex sample design of NHIS. Linear and quadratic trend tests of the estimated proportions across menopausal status were tested in SUDAAN via PROC DESCRIPT using the POLY option. Differences between percentages were evaluated using two-sided significance tests at the 0.05 level. About the authorAnjel Vahratian is with the National Center for Health Statistics, Division of Health Interview Statistics.

The author gratefully acknowledges the assistance of Lindsey Black in the preparation of this report. ReferencesFord ES. Habitual sleep duration and predicted 10-year cardiovascular risk using the pooled cohort risk equations among US adults. J Am Heart Assoc 3(6):e001454. 2014.Ford ES, Wheaton AG, Chapman DP, Li C, Perry GS, Croft JB.

Associations between self-reported sleep duration and sleeping disorder with concentrations of fasting and 2-h glucose, insulin, and glycosylated hemoglobin among adults without diagnosed diabetes. J Diabetes 6(4):338–50. 2014.American College of Obstetrics and Gynecology. ACOG Practice Bulletin No. 141.

Management of menopausal symptoms. Obstet Gynecol 123(1):202–16. 2014.Black LI, Nugent CN, Adams PF. Tables of adult health behaviors, sleep. National Health Interview Survey, 2011–2014pdf icon.

2016.Santoro N. Perimenopause. From research to practice. J Women’s Health (Larchmt) 25(4):332–9. 2016.Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, et al.

Recommended amount of sleep for a healthy adult. A joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. J Clin Sleep Med 11(6):591–2. 2015.Parsons VL, Moriarity C, Jonas K, et al. Design and estimation for the National Health Interview Survey, 2006–2015.

National Center for Health Statistics. Vital Health Stat 2(165). 2014.RTI International. SUDAAN (Release 11.0.0) [computer software]. 2012.

Suggested citationVahratian A. Sleep duration and quality among women aged 40–59, by menopausal status. NCHS data brief, no 286. Hyattsville, MD. National Center for Health Statistics.

2017.Copyright informationAll material appearing in this report is in the public domain and may be reproduced or copied without permission. Citation as to source, however, is appreciated.National Center for Health StatisticsCharles J. Rothwell, M.S., M.B.A., DirectorJennifer H. Madans, Ph.D., Associate Director for ScienceDivision of Health Interview StatisticsMarcie L. Cynamon, DirectorStephen J.

Blumberg, Ph.D., Associate Director for Science.

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After watching a http://www.ec-gliesberg-strasbourg.ac-strasbourg.fr/?page_id=1119 parent succumb to the deleterious effects of Alzheimer's disease, it's only natural to cialis side effects wonder if you might be doomed to the same fate. The good news?. That's cialis side effects not necessarily the case. The bad news, however, is that the disease is so prevalent your overall risk is still relatively high — especially as you age. At 65, you have a roughly 3 percent chance of contracting Alzheimer's disease cialis side effects each year.

This bumps up to a 17 percent chance after your 75th birthday, and increases to a roughly one in three chance you'll develop Alzheimer's after the age of 85. Experts agree that family history elevates the risk, particularly if you have more than one parent or sibling with the disease, but they disagree on how much. Some studies indicate the risk hovers at around cialis side effects 30 percent, while others estimate an up to two or four times increased risk. Early onset Alzheimer's — which typically strikes individuals between the ages of 40 and 65 — has a more easily understood genetic link, with a 50 percent chance the child of an Alzheimer's patient will also be diagnosed with the disease. Read More:Why cialis side effects Do Women Get Alzheimer’s More Than Men?.

How Did Alzheimer's Disease Get Its Name?. Are We Close to Curing Alzheimer’s Disease?. However, a combination of genetic and environmental factors come into play for the more common late-onset variation, says cialis side effects Rita Guerreiro, a neurogeneticist at the Van Andel Institute. Which makes things even more difficult to predict. €œMany people who have relatives with cialis side effects [Alzheimer's] never develop the disease, and many without a family history of the disease do develop it,” says Guerreiro.Interested in tipping the odds in your favor?.

Some scientists think keeping your mind active, consuming a diet low in red meat and sugar and exercising regularly could help keep the memory-zapping disease at bay.Late fall and early winter typically mean a flurry of holiday travel and get-togethers for a lot of people. But this year will be anything but normal. Making plans is more than a matter of shopping cialis side effects around for flight prices or car rental fees. Many of us are probably also asking ourselves whether to stay home or see loved ones, and how to stay safe at holiday gatherings. For the lowest risk of spreading or becoming sick with erectile dysfunction treatment, not traveling is the way cialis side effects to go.

However, there might be loved ones who desperately need companionship in the coming months. €œThere are situations where people will choose, and choose correctly, to go and support those family members,” says Lin H. Chen, director of the cialis side effects Travel Medicine Center at Mount Auburn Hospital and president of the International Society of Travel Medicine. No matter if you’re going cross-country to see siblings or staying at home with your dog, experts say, remember two things. Plan ahead and stay flexible.Tackle Logistics FirstFor those interested in interstate travel, first assess whether or not those plans are cialis side effects feasible.

The states you’re going to (and coming back to) might have rules about isolating yourself for two weeks once you arrive. If you live in one of those states but a two-week isolation period isn’t feasible — because you have to go to work or send kids to school, for example — then traveling for the holidays won’t work for you, says Gabriela Andujar Vazquez, an infectious disease doctor at Tufts Medical Center. Some states say that isolation requirements don’t apply if you get a cialis side effects negative erectile dysfunction treatment test. But testing you or your whole family may lie outside your budget if the exams aren’t covered by insurance, Andujar Vazquez says. Factor those financial decisions into cialis side effects your travel plans, too.If you do decide to travel, choose driving over flying if you can.

Busy rest stops might mean confronting crowds of other highway travelers, Chen says. However, compared to the entire process of flying — getting to an airport and waiting in lines repeatedly — driving likely means fewer crowds overall. €œThink about precautions through this journey,” cialis side effects Chen says, “not just on the plane, train, bus or car.”Airplanes themselves receive a lot of attention as potential cialis spreaders. But Chen says there are three instances of infected individuals spreading the disease to two or more people on a flight. Those transmissions happened before any airline required passengers cialis side effects to wear masks.

Since then, other interventions like leaving seats open, disinfecting often and updated air filtration have been introduced on airplanes, too. Though there’s no data yet on how effective these combined intervention strategies are, “the fact that we cialis side effects haven’t heard about masked transmission on recent flights is also reassuring,” Chen says. On the Big DayOdds are you’re debating travel plans for the sake of a big family meal. Or even if you’re staying local, you might try and work something out with friends and relatives nearby. Both Chen and Andujar Vazquez emphasize that no matter which you choose, keep up the erectile dysfunction treatment precautions cialis side effects once you’re all together.

Generally, the smaller the gathering (and the fewer number of households), the better. Keep activities outdoors if you can, seat groups apart, cialis side effects and keep masks on while not eating. You might also consider new ways to keep everyone fed. The typical buffet serving style can mean a lot of utensil sharing, so maybe opt for single-serving portioning or have everyone wash or sanitize hands before and after touching communal dishes. And as fun as it might be to play bartender, maybe choose a BYOB policy cialis side effects as well.

Oh, and “no one should be coming sick,” Andujar Vazquez says. €œYou cannot say that enough.”These might sound like a lot of holiday modifications, which is why it’s important to cialis side effects discuss what the situation will look like before coming together. €œPeople have to feel comfortable talking about these things, because it’s part of our daily life now,” Andujar Vazquez says. €œHave that conversation before the event happens so people don’t have unexpected surprises or feel unsafe with some sort of behavior.”At the same time, acknowledge that even the most careful planning might fall apart. Your destination might become cialis side effects a erectile dysfunction treatment hotspot days before you’re set to arrive, or you or someone in your gathering might start feeling unwell ahead of time.

Though it’s easier said than done, accept that plans will change whether you want them to or not — and that celebrations in the coming months will look different than they used to. €œRealistically, this holiday season cialis side effects is going to be difficult for a lot of people,” says Jonathan Kanter, psychologist and director of the Center for the Science of Social Connection at the University of Washington. In individuals coping with significant life changes, one of the best predictors of depression is whether or not people can leave former goals behind and adopt new ones, Kanter says. Letting go of old expectations — like how you normally gather with family, for example — can involve a kind of grieving process. But recalibrating what you want cialis side effects to get out of a situation is an essential coping skill.

€œYou won’t be able to get there unless you breathe and accept that you’re in a new context,” Kanter says. €œWith that acceptance, hopefully there's a lot of creativity and innovation and grace about how to make it as successful as possible.” cialis side effects The prospect of not seeing loved ones in the coming months might make some people nervous, for themselves and for others. What's important to remember is that it's possible to make it through — and that future holidays will get better.As flu season creeps up on the Northern Hemisphere, cold and flu relief medications will inevitably fly off store shelves. A natural remedy that shoppers might reach for is elderberry, a small, blackish-purple fruit that companies turn into syrups, lozenges and gummies. Though therapeutic uses of the berry date back centuries, Michael Macknin, a pediatrician at the Cleveland Clinic, hadn’t heard of using elderberry to treat the flu cialis side effects until a patient’s mother asked him about it.

Some industry-sponsored research claims that the herbal remedy could cut the length of the symptoms by up to four days. For a cialis side effects comparison, Tamiflu, an FDA-approved treatment, only reduces flu duration by about a single day. €œI said, 'Gee, if that’s really true [about elderberry], it would be a huge benefit,'” Macknin says. But the effectiveness and safety of elderberry is still fairly unclear. Unlike the over-the-counter medicines at your local pharmacy, cialis side effects elderberry hasn't been through rigorous FDA testing and approval.

However, Macknin and his team recently published a study in the Journal of General Internal Medicine, which found that elderberry treatments did nothing for flu patients. This prompts a need for further studies into the remedy — work that unfortunately stands a low chance of happening in the future, Macknin cialis side effects says. Looking For ProofElderberries are full of chemicals that could be good for your health. Like similar fruits, the berries contain high levels of antioxidants, compounds that shut down reactions in our bodies that damage cells. But whether or not elderberry's properties also help immune systems fend cialis side effects off a cialis is murky.

There are only a handful of studies that have examined if elderberries reduced the severity or duration of the flu. And though some of the work cialis side effects prior to Macknin’s was well-designed and supported this herbal remedy as a helpful flu aid, at least some — and potentially all — of those studies were funded by elderberry treatment manufacturers.Macknin says an elderberry supplement company provided his team with their products and a placebo version for free, generic cialis online europe but that the company wasn’t involved in the research beyond that. Macknin's study is the largest one conducted on elderberry to date, with 87 influenza patients completing the entire treatment course. Participants in the study were also welcome to take Tamiflu, for ethical cialis side effects reasons, as the team didn’t want to exclude anyone from taking a proven flu therapy. Additionally, each participant took home either a bottle of elderberry syrup or the placebo with instructions on when and how to take it.

The research team called participants every day for a symptom check and to remind them to take their medication.By chance, it turned out that a higher percentage of the patients given elderberry syrup had gotten their flu shot and also chose to take Tamiflu. Since the vaccination can reduce the severity of cialis side effects in recipients who still come down with the flu, the study coincidentally operated in favor of those who took the herbal remedy, Macknin says. Those patients could have dealt with a shorter, less-intense illness because of the Tamiflu and vaccination. €œEverything was stacked to have it turn out better [for the elderberry group],” Macknin says, “and it turned out the same.” The cialis side effects researchers found no difference in illness duration or severity between the elderberry and placebo groups. While analyzing the data, the team also found that those on the herbal treatment might have actually fared worse than those on the placebo.

The potential for this intervention to actually harm instead of help influenza patients explains why Macknin thinks the therapy needs further research.But, don't expect that work to happen any time soon. Researchers are faced with a number cialis side effects of challenges when it comes to studying the efficacy of herbal remedies. For starters, there's little financial incentive to investigate if they actually work. Plant products are challenging to patent, making cialis side effects them less lucrative prospects for pharmaceutical companies or research organizations to investigate. Additionally, investigations that try and prove a proposed therapy as an effective drug — like the one Macknin and his team accomplished — are expensive, Macknin says.

Those projects need FDA oversight and additional paperwork, components that drive up study costs. €œIt’s extraordinarily expensive and there’s no money cialis side effects in it for anybody,” Macknin says.Talk To Your DoctorUltimately, research on elderberry therapies for flu patients is a mixed bag, and deserves more attention from scientists. However, if you still want to discuss elderberry treatments for the flu with your doctor, that’s a conversation you should feel comfortable having, says Erica McIntyre, an expert focused on health and environmental psychology in the School of Public Health at the University of Technology Sydney. Navigating what research says about a particular herbal cialis side effects medicine is challenging for patients and health practitioners alike. The process is made more complex by the range of similar-sounding products on the market that lack standardized ingredients, McIntyre says.

But when doctors judge or shame patients for asking about non-conventional healthcare interventions, the response can distance people and push them closer to potentially unproven treatments. Even worse, those individuals cialis side effects might start to keep their herbal remedies a secret. €œIt is that fear about being judged for use of that medication,” McIntyre says, that drives up to 50 percent of people taking herbal treatments to withhold that information from healthcare practitioners. That’s a dangerous choice, as some herbal and traditional medications can interact and cause health problems.If a physician shames someone for asking about alternative medicines, it’s likely cialis side effects time to find a new doctor, McIntyre says. Look for someone who will listen to your concerns — whether it's that you feel traditional treatments haven’t worked for you, or that you didn’t like the side effects, the two common reasons people pursue herbal treatments in the first place.

€œYou’re not necessarily looking for a doctor that will let you do whatever you want,” McIntyre says, “but that they actually consider you as a patient, your treatment choices and your treatment priorities, and communicate in a way that’s supportive.” And if a doctor suggests that you avoid a treatment you’re interested in, ask why. They generally have a good reason, McIntyre says.For now, know that even if your doctor doesn’t support you cialis side effects taking elderberry, there are other proven preventative measures that are worth your while — like the flu shot. Anyone six months or older should get it, Macknin says, and stick to the protocols we’re used to following to prevent erectile dysfunction treatment s, like social distancing, mask-wearing and hand-washing. Those measures cialis side effects also help prevent flu transmission, too — something, so far, no elderberry supplement package can claim.The yearly influenza season threatens to make the erectile dysfunction treatment cialis doubly deadly, but I believe that this isn’t inevitable.There are two commonly given treatments – the pneumococcal treatment and the Hib treatment – that protect against bacterial pneumonias. These bacteria complicate both influenza and erectile dysfunction treatment, often leading to death.

My examination of disease trends and vaccination rates leads me to believe that broader use of the pneumococcal and Hib treatments could guard against the worst effects of a erectile dysfunction treatment illness.I am an immunologist and physiologist interested in the effects of combined s on immunity. I have reached my insight by juxtaposing two seemingly unrelated puzzles cialis side effects. Infants and children get erectile dysfunction, the cialis that causes erectile dysfunction treatment, but very rarely become hospitalized or die. And case numbers and death rates from erectile dysfunction treatment began varying greatly from nation to nation and city to city even before lockdowns began cialis side effects. I wondered why.One night I woke up with a possible answer.

Vaccination rates. Most children, beginning cialis side effects at age two months, are vaccinated against numerous diseases. Adults less so. And, both cialis side effects infant and adult vaccination rates vary widely across the world. Could differences in the rates of vaccination against one or more diseases account for differences in erectile dysfunction treatment risks?.

As someone who had previously investigated other cialiss such as the Great Flu cialis of 1918-19 and AIDS, and who has worked with treatments, I had a strong background for tracking down the relevant data to test my hypothesis.Pneumococcal Vaccination Rates Correlate With Lower erectile dysfunction treatment Cases and DeathsI cialis side effects gathered national and some local data on vaccination rates against influenza, polio, measles-mumps-rubella (MMR), diphtheria-tetanus-pertussis (DTP), tuberculosis (BCG), pneumococci and Haemophilus influenzae type B (Hib). I correlated them with erectile dysfunction treatment case rates and death rates for 24 nations that had experienced their erectile dysfunction treatment outbreaks at about the same time. I controlled for factors such as percentage of the population who were obese, diabetic or elderly.I found that only pneumococcal treatments afforded statistically significant protection against erectile dysfunction treatment. Nations such as Spain, Italy, Belgium, Brazil, Peru and Chile that have the highest erectile dysfunction treatment rates per million have the poorest pneumococcal vaccination cialis side effects rates among both infants and adults. Nations with the lowest rates of erectile dysfunction treatment – Japan, Korea, Denmark, Australia and New Zealand – have the highest rates of pneumococcal vaccination among both infants and adults.A recent preprint study (not yet peer-reviewed) from researchers at the Mayo Clinic has also reported very strong associations between pneumococcal vaccination and protection against erectile dysfunction treatment.

This is especially true among minority patients who are bearing the brunt of the erectile dysfunction cialis cialis side effects. The report also suggests that other treatments, or combinations of treatments, such as Hib and MMR may also provide protection.These results are important because in the U.S., childhood vaccination against pneumococci – which protects against Streptococcus pneumoniae bacteria – varies by state from 74% to 92%. Although the CDC recommends that all adults 18-64 in high risk groups for erectile dysfunction treatment and all adults over the age of 65 get a pneumococcal vaccination, only 23% of high-risk adults and 64% of those over the age of 65 do so.Similarly, although the CDC recommends at all infants and some high-risk adults be vaccinated against Haemophilus influenzae type B (Hib), only 80.7% of children in the U.S. And a cialis side effects handful of immunologically compromised adults have been. Pneumococcal and Hib vaccination rates are significantly lower in minority populations in the U.S.

And in countries that have been hit harder by erectile dysfunction treatment than the U.S.Based on these data, I advocate universal pneumococcal and Hib vaccination among cialis side effects children, at-risk adults and all adults over 65 to prevent serious erectile dysfunction treatment disease.Left. Combined rates of childhood and adult (over 65) pneumococcal vaccination (out of a possible 200). Right. Cases (per million) population of erectile dysfunction treatment at about 90 days cialis side effects into the cialis for 24 nations. Nations with high pneumococcal vaccination rates have low erectile dysfunction treatment case rates.

(Credit. CC BY-SA)How Pneumococcal Vaccination Protects Against erectile dysfunction treatmentProtection against serious erectile dysfunction treatment disease by pneumococcal and Hib treatments makes sense for several reasons. First, recent studies reveal that the majority of hospitalized erectile dysfunction treatment patients, and in some studies nearly all, are infected with streptococci, which causes pneumococcal pneumonias, Hib or other pneumonia-causing bacteria. Pneumococcal and Hib vaccinations should protect erectile dysfunction patients from these s and thus significantly cut the risk of serious pneumonia.I also found that pneumococcal, Hib and possibly rubella treatments may confer specific protection against the erectile dysfunction cialis that causes erectile dysfunction treatment by means of “molecular mimicry.”Molecular mimicry occurs when the immune system thinks one microbe looks like another. In this case, proteins found in pneumococcal treatments and, to a lesser degree, ones found in Hib and rubella treatments as well look like several proteins produced by the erectile dysfunction cialis.Two of these proteins found in pneumococcal treatments mimic the spike and membrane proteins that permit the cialis to infect cells.

This suggests pneumococcal vaccination may prevent erectile dysfunction . Two other mimics are the nucleoprotein and replicase that control cialis replication. These proteins are made after viral , in which case pneumococcal vaccination may control, but not prevent, erectile dysfunction replication.Either way, these treatments may provide proxy protection against erectile dysfunction that we can implement right now, even before we have a specific cialis treatment. Such protection may not be complete. People might still suffer a weakened version of erectile dysfunction treatment but, like most infants and children, be protected against the worst effects of the .Fighting Influenza-related Pneumonias During the erectile dysfunction treatment cialisWhile the specific protection these other treatments confer against erectile dysfunction treatment has not yet been tested in a clinical trial, I advocate broader implementation of pneumococcal and Hib vaccination for one additional, well-validated reason.Pneumococcal and Hib pneumonias – both caused by bacteria – are the major causes of death following viral influenza.

The influenza cialis rarely causes death directly. Most often, the cialis makes the lungs more susceptible to bacterial pneumonias, which are deadly. Dozens of studies around the world have demonstrated that increasing rates of pneumococcal and Hib vaccination dramatically lowers influenza-related pneumonias.Similar studies demonstrate that the price of using these treatments is balanced by savings due to lower rates of influenza-related hospitalizations, intensive care unit admissions and deaths. In the context of erectile dysfunction treatment, lowering rates of influenza-related hospitalizations and ICU admissions would free up resources to fight the erectile dysfunction, independent of any effect these treatments might have on erectile dysfunction itself. In my opinion, that is a winning scenario.In short, we need not wait for a erectile dysfunction treatment to slow down erectile dysfunction treatment.I believe that we can and should act now by fighting the erectile dysfunction with all the tools at our disposal, including influenza, Hib, pneumococcal and perhaps rubella vaccinations.Preventing pneumococcal and Hib complications of influenza and erectile dysfunction treatment, and perhaps proxy-vaccinating against erectile dysfunction itself, helps everyone.

Administering these already available and well-tested pneumococcal and Hib treatments to people will save money by freeing up hospital beds and ICUs. It will also improve public health by reducing the spread of multiple s and boost the economy by nurturing a healthier population.Robert Root-Bernstein is a Professor of Physiology at Michigan State University. This article was originally published on The Conversation under a Creative Commons liscense Read the original here..

After watching http://www.ec-gliesberg-strasbourg.ac-strasbourg.fr/?page_id=1119 a parent succumb to the deleterious effects of Alzheimer's disease, it's only natural to wonder if you might be doomed to cialis best buy the same fate. The good news?. That's not necessarily the cialis best buy case. The bad news, however, is that the disease is so prevalent your overall risk is still relatively high — especially as you age.

At 65, you have a roughly 3 percent chance of contracting Alzheimer's disease each cialis best buy year. This bumps up to a 17 percent chance after your 75th birthday, and increases to a roughly one in three chance you'll develop Alzheimer's after the age of 85. Experts agree that family history elevates the risk, particularly if you have more than one parent or sibling with the disease, but they disagree on how much. Some studies indicate the risk hovers at around 30 percent, while cialis best buy others estimate an up to two or four times increased risk.

Early onset Alzheimer's — which typically strikes individuals between the ages of 40 and 65 — has a more easily understood genetic link, with a 50 percent chance the child of an Alzheimer's patient will also be diagnosed with the disease. Read More:Why cialis best buy Do Women Get Alzheimer’s More Than Men?. How Did Alzheimer's Disease Get Its Name?. Are We Close to Curing Alzheimer’s Disease?.

However, a combination of genetic and cialis best buy environmental factors come into play for the more common late-onset variation, says Rita Guerreiro, a neurogeneticist at the Van Andel Institute. Which makes things even more difficult to predict. €œMany people who have relatives with [Alzheimer's] never develop the disease, and many without a family history of the disease do develop it,” says Guerreiro.Interested in tipping cialis best buy the odds in your favor?. Some scientists think keeping your mind active, consuming a diet low in red meat and sugar and exercising regularly could help keep the memory-zapping disease at bay.Late fall and early winter typically mean a flurry of holiday travel and get-togethers for a lot of people.

But this year will be anything but normal. Making plans is more than a matter of shopping around for flight prices or car cialis best buy rental fees. Many of us are probably also asking ourselves whether to stay home or see loved ones, and how to stay safe at holiday gatherings. For the lowest risk of spreading or becoming sick with erectile dysfunction treatment, cialis best buy not traveling is the way to go.

However, there might be loved ones who desperately need companionship in the coming months. €œThere are situations where people will choose, and choose correctly, to go and support those family members,” says Lin H. Chen, director of the cialis best buy Travel Medicine Center at Mount Auburn Hospital and president of the International Society of Travel Medicine. No matter if you’re going cross-country to see siblings or staying at home with your dog, experts say, remember two things.

Plan ahead and stay flexible.Tackle Logistics cialis best buy FirstFor those interested in interstate travel, first assess whether or not those plans are feasible. The states you’re going to (and coming back to) might have rules about isolating yourself for two weeks once you arrive. If you live in one of those states but a two-week isolation period isn’t feasible — because you have to go to work or send kids to school, for example — then traveling for the holidays won’t work for you, says Gabriela Andujar Vazquez, an infectious disease doctor at Tufts Medical Center. Some states say that isolation requirements don’t apply if you get a cialis best buy negative erectile dysfunction treatment test.

But testing you or your whole family may lie outside your budget if the exams aren’t covered by insurance, Andujar Vazquez says. Factor those financial decisions into your travel plans, too.If you do cialis best buy decide to travel, choose driving over flying if you can. Busy rest stops might mean confronting crowds of other highway travelers, Chen says. However, compared to the entire process of flying — getting to an airport and waiting in lines repeatedly — driving likely means fewer crowds overall.

€œThink about precautions through this journey,” Chen says, “not just on cialis best buy the plane, train, bus or car.”Airplanes themselves receive a lot of attention as potential cialis spreaders. But Chen says there are three instances of infected individuals spreading the disease to two or more people on a flight. Those transmissions happened before cialis best buy any airline required passengers to wear masks. Since then, other interventions like leaving seats open, disinfecting often and updated air filtration have been introduced on airplanes, too.

Though there’s no data yet on how effective these combined intervention strategies are, “the fact that we haven’t heard about masked transmission on recent flights is also cialis best buy reassuring,” Chen says. On the Big DayOdds are you’re debating travel plans for the sake of a big family meal. Or even if you’re staying local, you might try and work something out with friends and relatives nearby. Both Chen and Andujar Vazquez emphasize that no matter which you choose, keep up the erectile dysfunction treatment precautions once cialis best buy you’re all together.

Generally, the smaller the gathering (and the fewer number of households), the better. Keep activities outdoors if you can, seat groups apart, and keep masks on while not cialis best buy eating. You might also consider new ways to keep everyone fed. The typical buffet serving style can mean a lot of utensil sharing, so maybe opt for single-serving portioning or have everyone wash or sanitize hands before and after touching communal dishes.

And as fun as it might be to play bartender, maybe choose a BYOB policy as cialis best buy well. Oh, and “no one should be coming sick,” Andujar Vazquez says. €œYou cannot cialis best buy say that enough.”These might sound like a lot of holiday modifications, which is why it’s important to discuss what the situation will look like before coming together. €œPeople have to feel comfortable talking about these things, because it’s part of our daily life now,” Andujar Vazquez says.

€œHave that conversation before the event happens so people don’t have unexpected surprises or feel unsafe with some sort of behavior.”At the same time, acknowledge that even the most careful planning might fall apart. Your destination might become a erectile dysfunction treatment hotspot days before you’re set to arrive, or you or someone in your cialis best buy gathering might start feeling unwell ahead of time. Though it’s easier said than done, accept that plans will change whether you want them to or not — and that celebrations in the coming months will look different than they used to. €œRealistically, this holiday season is going to be difficult for a lot of people,” says Jonathan Kanter, psychologist and director of the Center for the Science of Social Connection at the University cialis best buy of Washington.

In individuals coping with significant life changes, one of the best predictors of depression is whether or not people can leave former goals behind and adopt new ones, Kanter says. Letting go of old expectations — like how you normally gather with family, for example — can involve a kind of grieving process. But recalibrating what you want to get out of a situation is an essential coping cialis best buy skill. €œYou won’t be able to get there unless you breathe and accept that you’re in a new context,” Kanter says.

€œWith that acceptance, hopefully there's a lot of creativity and innovation and grace about how to make it as successful as possible.” The prospect of not seeing loved ones in the coming months cialis best buy might make some people nervous, for themselves and for others. What's important to remember is that it's possible to make it through — and that future holidays will get better.As flu season creeps up on the Northern Hemisphere, cold and flu relief medications will inevitably fly off store shelves. A natural remedy that shoppers might reach for is elderberry, a small, blackish-purple fruit that companies turn into syrups, lozenges and gummies. Though therapeutic uses of the berry date back centuries, Michael Macknin, a pediatrician at the Cleveland Clinic, hadn’t heard of using elderberry to treat the flu until a patient’s mother asked him about cialis best buy it.

Some industry-sponsored research claims that the herbal remedy could cut the length of the symptoms by up to four days. For a comparison, Tamiflu, an FDA-approved treatment, only reduces cialis best buy flu duration by about a single day. €œI said, 'Gee, if that’s really true [about elderberry], it would be a huge benefit,'” Macknin says. But the effectiveness and safety of elderberry is still fairly unclear.

Unlike the over-the-counter medicines at your local pharmacy, elderberry hasn't been through rigorous FDA testing and approval cialis best buy. However, Macknin and his team recently published a study in the Journal of General Internal Medicine, which found that elderberry treatments did nothing for flu patients. This prompts a need for further studies into cialis best buy the remedy — work that unfortunately stands a low chance of happening in the future, Macknin says. Looking For ProofElderberries are full of chemicals that could be good for your health.

Like similar fruits, the berries contain high levels of antioxidants, compounds that shut down reactions in our bodies that damage cells. But whether or cialis best buy not elderberry's properties also help immune systems fend off a cialis is murky. There are only a handful of studies that have examined if elderberries reduced the severity or duration of the flu. And though some of can i buy cialis the work prior to Macknin’s was well-designed and cialis best buy supported this herbal remedy as a helpful flu aid, at least some — and potentially all — of those studies were funded by elderberry treatment manufacturers.Macknin says an elderberry supplement company provided his team with their products and a placebo version for free, but that the company wasn’t involved in the research beyond that.

Macknin's study is the largest one conducted on elderberry to date, with 87 influenza patients completing the entire treatment course. Participants in the cialis best buy study were also welcome to take Tamiflu, for ethical reasons, as the team didn’t want to exclude anyone from taking a proven flu therapy. Additionally, each participant took home either a bottle of elderberry syrup or the placebo with instructions on when and how to take it. The research team called participants every day for a symptom check and to remind them to take their medication.By chance, it turned out that a higher percentage of the patients given elderberry syrup had gotten their flu shot and also chose to take Tamiflu.

Since the vaccination can reduce the severity of in recipients who still cialis best buy come down with the flu, the study coincidentally operated in favor of those who took the herbal remedy, Macknin says. Those patients could have dealt with a shorter, less-intense illness because of the Tamiflu and vaccination. €œEverything was stacked to have it turn out better [for the elderberry group],” Macknin says, “and it turned out the same.” The researchers found cialis best buy no difference in illness duration or severity between the elderberry and placebo groups. While analyzing the data, the team also found that those on the herbal treatment might have actually fared worse than those on the placebo.

The potential for this intervention to actually harm instead of help influenza patients explains why Macknin thinks the therapy needs further research.But, don't expect that work to happen any time soon. Researchers are faced with a number of challenges when it comes cialis best buy to studying the efficacy of herbal remedies. For starters, there's little financial incentive to investigate if they actually work. Plant products are challenging to patent, making them less lucrative prospects for pharmaceutical companies or cialis best buy research organizations to investigate.

Additionally, investigations that try and prove a proposed therapy as an effective drug — like the one Macknin and his team accomplished — are expensive, Macknin says. Those projects need FDA oversight and additional paperwork, components that drive up study costs. €œIt’s extraordinarily expensive and there’s no money cialis best buy in it for anybody,” Macknin says.Talk To Your DoctorUltimately, research on elderberry therapies for flu patients is a mixed bag, and deserves more attention from scientists. However, if you still want to discuss elderberry treatments for the flu with your doctor, that’s a conversation you should feel comfortable having, says Erica McIntyre, an expert focused on health and environmental psychology in the School of Public Health at the University of Technology Sydney.

Navigating what research says about a particular herbal medicine is challenging for patients and health practitioners cialis best buy alike. The process is made more complex by the range of similar-sounding products on the market that lack standardized ingredients, McIntyre says. But when doctors judge or shame patients for asking about non-conventional healthcare interventions, the response can distance people and push them closer to potentially unproven treatments. Even worse, cialis best buy those individuals might start to keep their herbal remedies a secret.

€œIt is that fear about being judged for use of that medication,” McIntyre says, that drives up to 50 percent of people taking herbal treatments to withhold that information from healthcare practitioners. That’s a dangerous choice, as some herbal and traditional medications can interact and cause health problems.If a physician shames someone for asking about alternative medicines, it’s likely time to cialis best buy find a new doctor, McIntyre says. Look for someone who will listen to your concerns — whether it's that you feel traditional treatments haven’t worked for you, or that you didn’t like the side effects, the two common reasons people pursue herbal treatments in the first place. €œYou’re not necessarily looking for a doctor that will let you do whatever you want,” McIntyre says, “but that they actually consider you as a patient, your treatment choices and your treatment priorities, and communicate in a way that’s supportive.” And if a doctor suggests that you avoid a treatment you’re interested in, ask why.

They generally have a good reason, McIntyre says.For now, know that even if your doctor doesn’t support you taking elderberry, there are other proven preventative measures that are worth your while — like the flu cialis best buy shot. Anyone six months or older should get it, Macknin says, and stick to the protocols we’re used to following to prevent erectile dysfunction treatment s, like social distancing, mask-wearing and hand-washing. Those measures also help prevent flu transmission, too — something, so far, no elderberry supplement package can claim.The yearly influenza season threatens to make the erectile dysfunction treatment cialis doubly deadly, but I believe that this isn’t inevitable.There are two commonly given treatments – the pneumococcal treatment and the Hib treatment – that protect cialis best buy against bacterial pneumonias. These bacteria complicate both influenza and erectile dysfunction treatment, often leading to death.

My examination of disease trends and vaccination rates leads me to believe that broader use of the pneumococcal and Hib treatments could guard against the worst effects of a erectile dysfunction treatment illness.I am an immunologist and physiologist interested in the effects of combined s on immunity. I have reached my insight cialis best buy by juxtaposing two seemingly unrelated puzzles. Infants and children get erectile dysfunction, the cialis that causes erectile dysfunction treatment, but very rarely become hospitalized or die. And case numbers and death rates from erectile dysfunction treatment began varying greatly from nation to nation and city to city even before lockdowns cialis best buy began.

I wondered why.One night I woke up with a possible answer. Vaccination rates. Most children, beginning at age two months, are vaccinated cialis best buy against numerous diseases. Adults less so.

And, both infant and adult vaccination rates vary cialis best buy widely across the world. Could differences in the rates of vaccination against one or more diseases account for differences in erectile dysfunction treatment risks?. As someone who had previously investigated other cialiss such as the Great Flu cialis of 1918-19 and AIDS, and who has worked with treatments, I had a strong background cialis best buy for tracking down the relevant data to test my hypothesis.Pneumococcal Vaccination Rates Correlate With Lower erectile dysfunction treatment Cases and DeathsI gathered national and some local data on vaccination rates against influenza, polio, measles-mumps-rubella (MMR), diphtheria-tetanus-pertussis (DTP), tuberculosis (BCG), pneumococci and Haemophilus influenzae type B (Hib). I correlated them with erectile dysfunction treatment case rates and death rates for 24 nations that had experienced their erectile dysfunction treatment outbreaks at about the same time.

I controlled for factors such as percentage of the population who were obese, diabetic or elderly.I found that only pneumococcal treatments afforded statistically significant protection against erectile dysfunction treatment. Nations such as Spain, Italy, Belgium, Brazil, Peru and Chile that have the highest erectile dysfunction treatment rates per million have cialis best buy the poorest pneumococcal vaccination rates among both infants and adults. Nations with the lowest rates of erectile dysfunction treatment – Japan, Korea, Denmark, Australia and New Zealand – have the highest rates of pneumococcal vaccination among both infants and adults.A recent preprint study (not yet peer-reviewed) from researchers at the Mayo Clinic has also reported very strong associations between pneumococcal vaccination and protection against erectile dysfunction treatment. This is especially true among minority patients who are cialis best buy bearing the brunt of the erectile dysfunction cialis.

The report also suggests that other treatments, or combinations of treatments, such as Hib and MMR may also provide protection.These results are important because in the U.S., childhood vaccination against pneumococci – which protects against Streptococcus pneumoniae bacteria – varies by state from 74% to 92%. Although the CDC recommends that all adults 18-64 in high risk groups for erectile dysfunction treatment and all adults over the age of 65 get a pneumococcal vaccination, only 23% of high-risk adults and 64% of those over the age of 65 do so.Similarly, although the CDC recommends at all infants and some high-risk adults be vaccinated against Haemophilus influenzae type B (Hib), only 80.7% of children in the U.S. And a handful of immunologically compromised adults have been cialis best buy. Pneumococcal and Hib vaccination rates are significantly lower in minority populations in the U.S.

And in countries that have been hit harder by erectile dysfunction treatment than the U.S.Based on these data, I advocate universal pneumococcal and Hib vaccination among children, at-risk adults and all cialis best buy adults over 65 to prevent serious erectile dysfunction treatment disease.Left. Combined rates of childhood and adult (over 65) pneumococcal vaccination (out of a possible 200). Right. Cases (per million) population of erectile dysfunction treatment at about 90 days cialis best buy into the cialis for 24 nations.

Nations with high pneumococcal vaccination rates have low erectile dysfunction treatment case rates. (Credit. CC BY-SA)How Pneumococcal Vaccination Protects Against erectile dysfunction treatmentProtection against serious erectile dysfunction treatment disease by pneumococcal and Hib treatments makes sense for several reasons. First, recent studies reveal that the majority of hospitalized erectile dysfunction treatment patients, and in some studies nearly all, are infected with streptococci, which causes pneumococcal pneumonias, Hib or other pneumonia-causing bacteria.

Pneumococcal and Hib vaccinations should protect erectile dysfunction patients from these s and thus significantly cut the risk of serious pneumonia.I also found that pneumococcal, Hib and possibly rubella treatments may confer specific protection against the erectile dysfunction cialis that causes erectile dysfunction treatment by means of “molecular mimicry.”Molecular mimicry occurs when the immune system thinks one microbe looks like another. In this case, proteins found in pneumococcal treatments and, to a lesser degree, ones found in Hib and rubella treatments as well look like several proteins produced by the erectile dysfunction cialis.Two of these proteins found in pneumococcal treatments mimic the spike and membrane proteins that permit the cialis to infect cells. This suggests pneumococcal vaccination may prevent erectile dysfunction . Two other mimics are the nucleoprotein and replicase that control cialis replication.

These proteins are made after viral , in which case pneumococcal vaccination may control, but not prevent, erectile dysfunction replication.Either way, these treatments may provide proxy protection against erectile dysfunction that we can implement right now, even before we have a specific cialis treatment. Such protection may not be complete. People might still suffer a weakened version of erectile dysfunction treatment but, like most infants and children, be protected against the worst effects of the .Fighting Influenza-related Pneumonias During the erectile dysfunction treatment cialisWhile the specific protection these other treatments confer against erectile dysfunction treatment has not yet been tested in a clinical trial, I advocate broader implementation of pneumococcal and Hib vaccination for one additional, well-validated reason.Pneumococcal and Hib pneumonias – both caused by bacteria – are the major causes of death following viral influenza. The influenza cialis rarely causes death directly.

Most often, the cialis makes the lungs more susceptible to bacterial pneumonias, which are deadly. Dozens of studies around the world have demonstrated that increasing rates of pneumococcal and Hib vaccination dramatically lowers influenza-related pneumonias.Similar studies demonstrate that the price of using these treatments is balanced by savings due to lower rates of influenza-related hospitalizations, intensive care unit admissions and deaths. In the context of erectile dysfunction treatment, lowering rates of influenza-related hospitalizations and ICU admissions would free up resources to fight the erectile dysfunction, independent of any effect these treatments might have on erectile dysfunction itself. In my opinion, that is a winning scenario.In short, we need not wait for a erectile dysfunction treatment to slow down erectile dysfunction treatment.I believe that we can and should act now by fighting the erectile dysfunction with all the tools at our disposal, including influenza, Hib, pneumococcal and perhaps rubella vaccinations.Preventing pneumococcal and Hib complications of influenza and erectile dysfunction treatment, and perhaps proxy-vaccinating against erectile dysfunction itself, helps everyone.

Administering these already available and well-tested pneumococcal and Hib treatments to people will save money by freeing up hospital beds and ICUs. It will also improve public health by reducing the spread of multiple s and boost the economy by nurturing a healthier population.Robert Root-Bernstein is a Professor of Physiology at Michigan State University. This article was originally published on The Conversation under a Creative Commons liscense Read the original here..

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En Español During my trip to Wisconsin this cialis alcohol past week, I met with Voces de la Frontera Action, an organization dedicated to protecting and expanding immigrant workers' rights through leadership development, community organizing and empowerment. I am grateful to the workers who shared their stories with me. In many ways, they reminded me of the story of my cialis alcohol own parents who immigrated to America seeking better work opportunities. Immigrant workers have long contributed a great deal to our communities and are a critical part of our economy. This became especially clear during the cialis, when immigrants served as essential frontline workers and kept us moving forward — proving once again that our nation depends on them.

But far too often their work is undervalued and their cialis alcohol rights ignored. As a nation built by immigrants, we have to do better. The Biden-Harris administration knows this, which is why the American Jobs Plan invests billions in programs that will expand pathways to good-paying jobs for immigrant workers. And through the White cialis alcohol House Task Force on Worker Organizing and Empowerment – a task force I’m proud to vice chair – we empower immigrant workers to advocate for better working conditions and wages. In the last five years, the Department of Labor has recovered more than $1.4 billion in back wages owed to workers, regardless of where they were born or what their immigration status was.

This is the right thing to do — and it also helps level the playing field level for employers who obey the rules. The Department of Labor's mission is to protect cialis alcohol all workers. The fight for immigrant rights and the fight for workers' rights are inseparable, and I remain personally committed to advancing policies that empower all workers.Marty Walsh is the secretary of labor. Follow him on Twitter and Instagram at @SecMartyWalsh. Empoderando a Trabajadores Inmigrantes El sueño Americano debería ser accesible para todos cialis alcohol los trabajadores, pero ese no es el caso para muchos inmigrantes.

Durante mi viaje a Wisconsin la semana pasada me reuní con Voces de la Frontera Action, una organización dedicada a proteger y ampliar los derechos de los trabajadores inmigrantes a través del desarrollo de liderazgo, la organización comunitaria y empoderamiento. Estoy muy agradecido con los trabajadores que compartieron conmigo sus historias. En muchos sentidos, éstas me recordaron la de mis propios padres, cialis alcohol quienes emigraron a Estados Unidos en busca de mejores oportunidades laborales. Desde hace mucho tiempo los trabajadores inmigrantes han contribuido considerablemente a nuestras comunidades y son parte fundamental de nuestra economía. Esto claramente se puso de manifiesto durante la pandemia, donde los inmigrantes fueron trabajadores esenciales de primera línea que nos mantuvieron en pie, demostrando una vez más que nuestra nación depende de ellos.

Sin embargo, con demasiada frecuencia su trabajo se cialis alcohol infravalora y sus derechos son ignorados. Como nación construida por inmigrantes, debemos hacerlo mejor. La administración Biden-Harris lo sabe, y es por eso que el Plan de Empleo Estadounidense invierte miles de millones en programas que abrirán caminos hacia empleos bien pagados para trabajadores inmigrantes. Y a través del Grupo de Trabajo de la Casa Blanca sobre la Organización y Empoderamiento de Trabajadores - grupo del que me enorgullece ser vicepresidente - empoderamos cialis alcohol a los trabajadores inmigrantes para que reclamen por mejores salarios y condiciones laborales. En los últimos cinco años, el Departamento de Trabajo ha recuperado más de $1.4 mil millones en salarios atrasados ​​adeudados a trabajadores sin importar dónde nacieron o cuál era su estado migratorio.

Es lo correcto - y también ayuda a nivelar el campo de juego para los empleadores que cumplen las reglas laborales. La misión del Departamento cialis alcohol de Trabajo es proteger a todos los trabajadores. La lucha por los derechos de los inmigrantes y la lucha por los derechos de los trabajadores son inseparables, y mantengo mi compromiso personal a favor del avance de políticas que empoderen a todos los trabajadores. Marty Walsh es el secretario de trabajo. Sígalo por Twitter @SecMartyWalsh.Date published cialis alcohol.

April 21, 2021Date updated. May 5, 2021This notice outlines the safety and effectiveness requirements for Class I medical masks and face coverings with anti-microbial claims. This notice is for manufacturers using either an interim order cialis alcohol (IO) authorization or medical device establishment licence (MDEL) to manufacture, import or sell these devices in Canada.This notice does not cover anti-microbial agents sold separately and applied to face coverings or medical masks prior to use. On this page About masks with anti-microbial substances The erectile dysfunction treatment cialis has created a public health requirement to wear face coverings and medical masks. Face coverings are not classified as medical devices unless there are medical claims or representations.Some mask and face covering medical devices may incorporate or be coated with materials that claim to be anti-microbial.

Anti-microbial substances may kill or inhibit the growth of microorganisms cialis alcohol. Some examples of anti-microbial substances include, but are not limited to. Silver copper Nanoform Graphene fabric coatings saltTo date, Health Canada has not received any data that support the safety and effectiveness of these substances when used with masks or face coverings. It is also not known whether cialis alcohol these substances improve the performance of medical masks in a measurable way. Regulatory considerations and claimsIn Canada, face coverings that are used only to reduce droplets or aerosols passing between individuals are not regulated as medical devices.

However, if the product label includes anti-microbial claims, these face coverings become Class I medical devices.Section 25 of the Medical Device Regulations allows for the request of supporting safety, effectiveness and quality information from Class I manufacturers. Limitations to the claimsBacterial Fiation Efficiency (BFE) is a measurement of a medical mask material's resistance to penetration of cialis alcohol aerosolized droplets of a culture suspension of Staphylococcus aureus (3.0 um or 3000 nm in size). Results are reported as percent efficiency and correlate with the ability of the fabric to resist bacterial penetration. Higher BFE percentages in this test cialis alcohol indicate better barrier efficiency. In general, a BFE rating could be interpreted as material fiation efficiency.This measurement is not to be taken in isolation and without a reference to a test method or international standard.

To achieve a high level of fiation, anti-microbial non-medical masks should be manufactured from a non-woven polypropylene material. All claims must be supported cialis alcohol by evidence and available for review upon request. Safety and effectiveness requirementsMedical masks or other personal protective equipment claiming microbial protection should meet the safety and effectiveness requirements described below. This information must be available for review upon request in the case of MDEL holders. It should be submitted cialis alcohol by manufacturers filing an interim order (IO) application or responding to regulatory requests for information.

A clear intended use/indications statement for the product along with complete labelling. Labelling includes user manuals, instructions for use (IFU), directions for use (DFU), outer package labelling, promotional material and website links. A detailed description cialis alcohol of the list of materials (for example, chemical and popular/trade names) and their technical specifications (for example, physical/chemical properties), used in the manufacture of the mask. This includes all material constituents added to the mask to impart anti-microbial or anti-viral properties. A full description of how the anti-microbial or anti-viral technology (for example, coatings) is produced and incorporated into, or bonded with, the mask materials, as well as a mechanistic description of the expected anti-microbial action.

If the anti-microbial substances are present in nanoform(s), a characterization of those substances cialis alcohol (for example, derivitization, layers, platelets, thickness, lateral dimensions, charged sites), including a certificate of analysis showing impurities. Information describing potential inhalation exposure to anti-microbial substance particulates that includes at least. intended use pattern (such as frequency, number of uses) summarized test data that fully characterize the amount (mass) and sizes (particle size distribution and mass median aerodynamic diameter - MMAD) of particulates that are shed during the intended use pattern and human inhalation exposure range estimates in terms of mg/L/hr, and mg/kg-bw/day, based on the information in a) and b) Evidence in the form of test reports that support all anti-viral (anti-erectile dysfunction treatment) and/or antimicrobial claims made on the product label. This may include the use of cialis alcohol one or more scientifically justified surrogate cialis(es). The test reports should describe the testing procedure and include a detailed description of the specific component/materials that were tested.

The test samples should be identical to the product. If there are differences between the test samples and cialis alcohol the final product (e.g. Different materials, concentrations, or other properties) these should be clearly described along with providing a justification for how the samples are representative of the final product in spite of these differences. Evidence of biocompatibility demonstrating that the patient-contacting materials in the final product are non-cytotoxic (ISO 10993-5), non-irritating, and non-sensitizing (ISO 10993-10). Performance data/reports demonstrating that the respirators/masks meet ASTM F2100, EN 14683, EN 149 and GB2626 (or cialis alcohol any other standards claimed).

If it is claimed that the mask can be washed, then instructions for washing should be provided. In addition, evidence must be provided that the performance claims made (for example, in 6 and 9 above) are maintained after a proposed maximum number of wash cycles as indicated in the device labelling. International activityThe U.S cialis alcohol. Food and Drug Administration regulates face coverings with anti-microbial claims as medical devices.Self-sanitizing claims are detergent claims that are overseen by the Pest Management Regulatory Agency in Canada and the Environmental Protection Agency in the United States. Related links Glossary of terms Face coverings (also known as non-medical masks).

Source control masks (to help cialis alcohol control an infected wearer from transmitting the cialis to others) that are made from a variety of woven fabrics. Face coverings may be made of different combinations of fabrics, layering sequences and available in diverse shapes. They are a sewn mask secured with ties or straps around the head or behind the ears. They are factory-made or made from household items such as scarves or t-shirts cialis alcohol. The fabrics and/or materials used in face coverings are not the same as the ones used in medical masks or respirators.

Medical device. A device within the meaning of the Food and Drugs Act, but does not include any device that is cialis alcohol intended for use in relation to animals. Medical masks. Includes surgical, procedural, isolation and other control devices intended to offer protection to the wearer. They are designed with 3-4 layers cialis alcohol of non-woven materials and meet labelled fiation levels (≥ 95%) using recognized standards.

Personal protective equipment (PPE). Personal protective equipment consists of gowns, gloves, masks, facial protection (masks and eye protection, face shields or masks with visor attachment) or respirators. They can be used by health care workers to provide cialis alcohol a barrier that will prevent potential exposure to infectious microorganisms. Respirator. A device that is tested and certified by procedures established by testing and certification agencies recognized by the authority having jurisdiction and is used to protect the user from inhaling a hazardous atmosphere.

The most common respirator used in health care is a N95 half-face piece filtering respirator. It's a personal protective device that fits tightly around the nose and mouth of the wearer. It's used to reduce the risk of inhaling hazardous airborne particles and aerosols, including dust particles and infectious agents..

En Español During my trip to Wisconsin this past week, I met with Voces de la Frontera Action, an organization dedicated to protecting and expanding cialis best buy immigrant workers' rights through leadership development, community organizing and empowerment. I am grateful to the workers who shared their stories with me. In many ways, they reminded me of the story cialis best buy of my own parents who immigrated to America seeking better work opportunities.

Immigrant workers have long contributed a great deal to our communities and are a critical part of our economy. This became especially clear during the cialis, when immigrants served as essential frontline workers and kept us moving forward — proving once again that our nation depends on them. But far too often their work is undervalued and their rights ignored cialis best buy.

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The fight for immigrant rights and the fight for workers' rights are inseparable, and I remain personally committed to advancing policies that empower all workers.Marty Walsh is the secretary of labor. Follow him on Twitter and Instagram at @SecMartyWalsh. Empoderando a Trabajadores Inmigrantes El sueño Americano debería ser accesible para todos cialis best buy los trabajadores, pero ese no es el caso para muchos inmigrantes.

Durante mi viaje a Wisconsin la semana pasada me reuní con Voces de la Frontera Action, una organización dedicada a proteger y ampliar los derechos de los trabajadores inmigrantes a través del desarrollo de liderazgo, la organización comunitaria y empoderamiento. Estoy muy agradecido con los trabajadores que compartieron conmigo sus historias. En muchos sentidos, éstas me recordaron la de mis propios padres, quienes emigraron a cialis best buy Estados Unidos en busca de mejores oportunidades laborales.

Desde hace mucho tiempo los trabajadores inmigrantes han contribuido considerablemente a nuestras comunidades y son parte fundamental de nuestra economía. Esto claramente se puso de manifiesto durante la pandemia, donde los inmigrantes fueron trabajadores esenciales de primera línea que nos mantuvieron en pie, demostrando una vez más que nuestra nación depende de ellos. Sin embargo, con demasiada frecuencia su trabajo se infravalora y sus derechos son ignorados cialis best buy.

Como nación construida por inmigrantes, debemos hacerlo mejor. La administración Biden-Harris lo sabe, y es por eso que el Plan de Empleo Estadounidense invierte miles de millones en programas que abrirán caminos hacia empleos bien pagados para trabajadores inmigrantes. Y a través del Grupo de Trabajo de la Casa cialis best buy Blanca sobre la Organización y Empoderamiento de Trabajadores - grupo del que me enorgullece ser vicepresidente - empoderamos a los trabajadores inmigrantes para que reclamen por mejores salarios y condiciones laborales.

En los últimos cinco años, el Departamento de Trabajo ha recuperado más de $1.4 mil millones en salarios atrasados ​​adeudados a trabajadores sin importar dónde nacieron o cuál era su estado migratorio. Es lo correcto - y también ayuda a nivelar el campo de juego para los empleadores que cumplen las reglas laborales. La misión cialis best buy del Departamento de Trabajo es proteger a todos los trabajadores.

La lucha por los derechos de los inmigrantes y la lucha por los derechos de los trabajadores son inseparables, y mantengo mi compromiso personal a favor del avance de políticas que empoderen a todos los trabajadores. Marty Walsh es el secretario de trabajo. Sígalo por cialis best buy Twitter @SecMartyWalsh.Date published.

April 21, 2021Date updated. May 5, 2021This notice outlines the safety and effectiveness requirements for Class I medical masks and face coverings with anti-microbial claims. This notice is for manufacturers using either an interim order (IO) authorization or medical device establishment licence (MDEL) to manufacture, import or sell these devices in Canada.This notice does not cover anti-microbial agents sold separately and applied to face coverings or medical masks prior to use cialis best buy.

On this page About masks with anti-microbial substances The erectile dysfunction treatment cialis has created a public health requirement to wear face coverings and medical masks. Face coverings are not classified as medical devices unless there are medical claims or representations.Some mask and face covering medical devices may incorporate or be coated with materials that claim to be anti-microbial. Anti-microbial substances may kill or inhibit the growth of cialis best buy microorganisms.

Some examples of anti-microbial substances include, but are not limited to. Silver copper Nanoform Graphene fabric coatings saltTo date, Health Canada has not received any data that support the safety and effectiveness of these substances when used with masks or face coverings. It is also not known whether these substances improve the cialis best buy performance of medical masks in a measurable way.

Regulatory considerations and claimsIn Canada, face coverings that are used only to reduce droplets or aerosols passing between individuals are not regulated as medical devices. However, if the product label includes anti-microbial claims, these face coverings become Class I medical devices.Section 25 of the Medical Device Regulations allows for the request of supporting safety, effectiveness and quality information from Class I manufacturers. Limitations to the claimsBacterial Fiation Efficiency (BFE) is a measurement of a medical mask material's resistance to penetration of aerosolized droplets of a cialis best buy culture suspension of Staphylococcus aureus (3.0 um or 3000 nm in size).

Results are reported as percent efficiency and correlate with the ability of the fabric to resist bacterial penetration. Higher BFE percentages in this test indicate better barrier cialis best buy efficiency. In general, a BFE rating could be interpreted as material fiation efficiency.This measurement is not to be taken in isolation and without a reference to a test method or international standard.

To achieve a high level of fiation, anti-microbial non-medical masks should be manufactured from a non-woven polypropylene material. All claims must be supported by evidence and available for review upon cialis best buy request. Safety and effectiveness requirementsMedical masks or other personal protective equipment claiming microbial protection should meet the safety and effectiveness requirements described below.

This information must be available for review upon request in the case of MDEL holders. It should be submitted by manufacturers filing an interim order (IO) application or responding to cialis best buy regulatory requests for information. A clear intended use/indications statement for the product along with complete labelling.

Labelling includes user manuals, instructions for use (IFU), directions for use (DFU), outer package labelling, promotional material and website links. A detailed description of the list of materials (for example, chemical and popular/trade names) and their technical specifications (for example, physical/chemical cialis best buy properties), used in the manufacture of the mask. This includes all material constituents added to the mask to impart anti-microbial or anti-viral properties.

A full description of how the anti-microbial or anti-viral technology (for example, coatings) is produced and incorporated into, or bonded with, the mask materials, as well as a mechanistic description of the expected anti-microbial action. If the anti-microbial substances are present in nanoform(s), a characterization of those substances (for example, derivitization, layers, platelets, thickness, lateral dimensions, charged sites), including a certificate of analysis cialis best buy showing impurities. Information describing potential inhalation exposure to anti-microbial substance particulates that includes at least.

intended use pattern (such as frequency, number of uses) summarized test data that fully characterize the amount (mass) and sizes (particle size distribution and mass median aerodynamic diameter - MMAD) of particulates that are shed during the intended use pattern and human inhalation exposure range estimates in terms of mg/L/hr, and mg/kg-bw/day, based on the information in a) and b) Evidence in the form of test reports that support all anti-viral (anti-erectile dysfunction treatment) and/or antimicrobial claims made on the product label. This may include the use of one or more scientifically justified surrogate cialis best buy cialis(es). The test reports should describe the testing procedure and include a detailed description of the specific component/materials that were tested.

The test samples should be identical to the product. If there cialis best buy are differences between the test samples and the final product (e.g. Different materials, concentrations, or other properties) these should be clearly described along with providing a justification for how the samples are representative of the final product in spite of these differences.

Evidence of biocompatibility demonstrating that the patient-contacting materials in the final product are non-cytotoxic (ISO 10993-5), non-irritating, and non-sensitizing (ISO 10993-10). Performance data/reports demonstrating that the respirators/masks meet ASTM F2100, EN 14683, EN 149 cialis best buy and GB2626 (or any other standards claimed). If it is claimed that the mask can be washed, then instructions for washing should be provided.

In addition, evidence must be provided that the performance claims made (for example, in 6 and 9 above) are maintained after a proposed maximum number of wash cycles as indicated in the device labelling. International activityThe cialis best buy U.S. Food and Drug Administration regulates face coverings with anti-microbial claims as medical devices.Self-sanitizing claims are detergent claims that are overseen by the Pest Management Regulatory Agency in Canada and the Environmental Protection Agency in the United States.

Related links Glossary of terms Face coverings (also known as non-medical masks). Source control masks (to help control an infected wearer from transmitting the cialis to others) that are made cialis best buy from a variety of woven fabrics. Face coverings may be made of different combinations of fabrics, layering sequences and available in diverse shapes.

They are a sewn mask secured with ties or straps around the head or behind the ears. They are factory-made or made from household cialis best buy items such as scarves or t-shirts. The fabrics and/or materials used in face coverings are not the same as the ones used in medical masks or respirators.

Medical device. A device within the meaning of the Food and Drugs Act, but does cialis best buy not include any device that is intended for use in relation to animals. Medical masks.

Includes surgical, procedural, isolation and other control devices intended to offer protection to the wearer. They are designed with 3-4 layers of cialis best buy non-woven materials and meet labelled fiation levels (≥ 95%) using recognized standards. Personal protective equipment (PPE).

Personal protective equipment consists of gowns, gloves, masks, facial protection (masks and eye protection, face shields or masks with visor attachment) or respirators. They can be cialis best buy used by health care workers to provide a barrier that will prevent potential exposure to infectious microorganisms. Respirator.

A device that is tested and certified by procedures established by testing and certification agencies recognized by the authority having jurisdiction and is used to protect the user from inhaling a hazardous atmosphere. The most common cialis best buy respirator used in health care is a N95 half-face piece filtering respirator. It's a personal protective device that fits tightly around the nose and mouth of the wearer.

It's used to reduce the risk of inhaling hazardous airborne particles and aerosols, including dust particles and infectious agents..